20100006004 CASE PRESENTATION

LONG CASE

 57 M came to casualty with c/o generalised weakness since 1 month ,fever since 1 week,altered sensorium since 3 days.


HOPI:

Since 1 month he has been complaining of generalised weakness. Since 15 days he has been feeling cold(even though it is summer) and has been switching off all the fans in the house. 

He has been suffering with constipation since 10 days. Has not passed stools at all(confirmed by the attender) He did not take any medication for it
He also complained of abdominal distension/bloating due to not passing stools.

Since 1 week he has fever insidious in onset gradually progressive, high grade. Associated with body pains.Not Associated with chills and rigor. Not relieved with medication.Not associated with nausea, vomiting, burning micturition, headache.

Since 3 days -he fell in the washroom two times(on 22/5/1023)and was not able to get up. When his family members found him, he had slurring of speech and altered sensorium.They took him to the Nalgonda government hospital.
There they gave him an enema and his constipation and bloating was relieved immediately.
They also treated him symptomatically. But he was still in altered sensorium and did not cover
They then shifted him to a private hospital as they had contacts there. There they did MRI and found that infarct in the cortical and subcortical regions of occiput.
but due to too expensive in that hospital so after tracheostomy in view of low GCS (24/05/23 morning) they came to our hospital. On the way in the ambulance, he was able to recognise his family. They brought him to the casualty .
On 30/5/2023: 
He developed scrotal swelling at afternoon.
Surgery referral taken:
On P/A examination:
Crepts + ,over abdomen wall b/l lateral aspects extending upto upper 1/3 rd aspects rt thigh and 2/3 rd of lt thigh.
L/E : scrotal edema + , no local raise of temp. Tenderness can't be elicited. 
Scrotal skin rugocities absent.
Creptations + in scrotum on palpation.
No fluctuation,get above the swelling+.
Diagnosis- surgical emphysema.
Advised - no surgical intervention needed. Emphysema will resolve spontaneously.if persists then plan for skin Nick's.

He developed SOB, sudden in onset,grade 4 MMR, orthopnea present , No PND.
Pulmonology refferal was taken I/v/o sob and fall in saturations,tachycardia and tachypnea.
Pt. Is connected to the mechnical ventilation i/v/o fall in saturation,tachypnea and tachycardia. 
They advised chest x ray - 
chest x ray PA view showed pneumothorax.
 On percussion- hyperresonant .
Needle thoracocentesis was immediately started than ICD was placed at 5 th ICS.
On 10/6/2023: 
repositioning of ICD was done.
On15/6/2023:
Blood transfusion was done.
O 16/6/2023: 
C/o suprapubic bulge from Night onwards.
Urology referral was taken:
On P/A soft, tenderness+ in all quadrants of abdomen. Suprapubic tenderness +.
Foley's Insitu. Scrotum normal.
Advised USG abdomen

InPast history
In 2019 end of the year- He has felt "weak" . One fine day he fell down(due to low energy) while cycling and was immediately rushed to the hospital. They told him his cervical nerves got compressed and said he needed surgery. But due to family issues, he didn't get surgery then, and got it done after 2 months( cervical spondylosis surgery). He recovered after 6 months and started walking with support of a stick since then. The doctors then discovered he had problems in the lumbar region as well (4 years back) and needed surgery too, but didn't give consent for that surgery as they told him he would never be able to walk.
H/o htn since 4 years using medication irregularly
N/k/c/ DM, asthma, epilepsy, thyroid, CAD

Personal history: 
Diet-mixed
Appetite - normal
Sleep - adequate
Bowel and bladder - bowel (constipation),bladder normal.
Addiction - drinks toddy occasionally

General Examination:
Patient is C/C/C
Moderately build and nourished.
No pallor,icterus,cynosis,clubbing, lymphadenopathy,pedal edema.

Vitals
Temp 101F
Bp -130/90 mmhg
Pr -102 bpm
Rr - 20 cpm
Spo2 100% on 4 liters of RA

Systemic examination:
CNS: 
GCS- E4 V (NT) M6
Power - 
         Rt. Lt
UL - 4/5 4/5
LL - 3/5 3/5
TONE 
UL - N. N
LL - N. N
Reflexes
B - 3+. 3+
T - 3+. 3+
S- 2+. 2+
K - 2+. 2+
A - 1+ 1+
Plantar - extension of big toe in both limbs


RS- bilateral air entry present
Bilateral infra axillary coarse crepts
       NVBS
Decreased movements on left infrascapular region

CVS- S1s2present, no murmurs heard
PA- soft and non tender.
 
PROVISIONAL DIAGNOSIS:

CVA with Acute ischemic stroke (infarct in right occipital lobe ) with Hyponatremia (resolved) with AKI on CKD (resolved) with k/c/o HTN since 3 yrs.
 
Investigations
24/5/2023:-
CUE-
Albumin:++
Sugar. - nil
Pus cells- 1-2 
Epithelial cells -1-2
*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-
*APTT- 35 Sec
*PT- 18 Sec
*INR - 1.33
*CSF ANALYSIS:
Sugar- 60 mg/dl
Protein - 25 mg/dl
Chloride -119 mmol/L
*Serum electrolytes:
Sodium - 138mEq/L
Potassium - 3.3 mEq/L
Chloride - 99 mEq/L
Calcium ionized - 1.01 mmol/K

26/5/2023:-
*Blood urea- 35 mg/dl
*Serum Creatinine - 1.0 mg/dl
*Serum electrolytes:-
Sodium - 135mEq/L
Potassium- 3.2 mEq/L
Chloride- 98mEq/L
Calcium ionized - 1.09 mmol/L
*24 hours urine protein/Creatinine Ratio:-
24hrs urine protein - 2304 mg/day
24hrs urine Creatinine - 1.02 g/day
Ratio- 2.30
Urine volume- 3,200 ml
*24 hours urinary chloride:- 402 mmol/day
*24 hours urinary sodium:- 436 mmol/day
*Bacterial culture and sensitivity:-
Blood- skin commensals growth
Urine- No growth.

27/5/2023:-
Hb:-11.4 gm/dl
TLC:-17,400 cells/cumm
Neutrophils:-90 %
lymphocytes:-5%
Eosinophils:-0 
Pcv- 33.7vol%
RBC count - 3.78 millions /cumm
Platelet count- 1.75 lakhs/cumm



24/5/2023:-
CUE-
Albumin:++
Sugar. - nil
Pus cells- 1-2 
Epithelial cells -1-2
*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-
*APTT- 35 Sec
*PT- 18 Sec
*INR - 1.33
*CSF ANALYSIS:
Sugar- 60 mg/dl
Protein - 25 mg/dl
Chloride -119 mmol/L
*Serum electrolytes:
Sodium - 138mEq/L
Potassium - 3.3 mEq/L
Chloride - 99 mEq/L
Calcium ionized - 1.01 mmol/K

26/5/2023:-
*Blood urea- 35 mg/dl
*Serum Creatinine - 1.0 mg/dl
*Serum electrolytes:-
Sodium - 135mEq/L
Potassium- 3.2 mEq/L
Chloride- 98mEq/L
Calcium ionized - 1.09 mmol/L
*24 hours urine protein/Creatinine Ratio:-
24hrs urine protein - 2304 mg/day
24hrs urine Creatinine - 1.02 g/day
Ratio- 2.30
Urine volume- 3,200 ml
*24 hours urinary chloride:- 402 mmol/day
*24 hours urinary sodium:- 436 mmol/day
*Bacterial culture and sensitivity:-
Blood- skin commensals growth
Urine- No growth.

27/5/2023:-
Hb:-11.4 gm/dl
TLC:-17,400 cells/cumm
Neutrophils:-90 %
lymphocytes:-5%
Eosinophils:-0 
Pcv- 33.7vol%
RBC count - 3.78 millions /cumm
Platelet count- 1.75 lakhs/cumm


24/5/2023:-
CUE-
Albumin:++
Sugar. - nil
Pus cells- 1-2 
Epithelial cells -1-2
*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-
*APTT- 35 Sec
*PT- 18 Sec
*INR - 1.33
*CSF ANALYSIS:
Sugar- 60 mg/dl
Protein - 25 mg/dl
Chloride -119 mmol/L
*Serum electrolytes:
Sodium - 138mEq/L
Potassium - 3.3 mEq/L
Chloride - 99 mEq/L
Calcium ionized - 1.01 mmol/K

26/5/2023:-
*Blood urea- 35 mg/dl
*Serum Creatinine - 1.0 mg/dl
*Serum electrolytes:-
Sodium - 135mEq/L
Potassium- 3.2 mEq/L
Chloride- 98mEq/L
Calcium ionized - 1.09 mmol/L
*24 hours urine protein/Creatinine Ratio:-
24hrs urine protein - 2304 mg/day
24hrs urine Creatinine - 1.02 g/day
Ratio- 2.30
Urine volume- 3,200 ml
*24 hours urinary chloride:- 402 mmol/day
*24 hours urinary sodium:- 436 mmol/day
*Bacterial culture and sensitivity:-
Blood- skin commensals growth
Urine- No growth.

27/5/2023:-
Hb:-11.4 gm/dl
TLC:-17,400 cells/cumm
Neutrophils:-90 %
lymphocytes:-5%
Eosinophils:-0 
Pcv- 33.7vol%
RBC count - 3.78 millions /cumm
Platelet count- 1.75 lakhs/cumm

24/5/2023:-
CUE-
Albumin:++
Sugar. - nil
Pus cells- 1-2 
Epithelial cells -1-2
*SERUM FOR OSMOLALITY: 293 m OSM/Kg

25/5/2024:-
*APTT- 35 Sec
*PT- 18 Sec
*INR - 1.33
*CSF ANALYSIS:
Sugar- 60 mg/dl
Protein - 25 mg/dl
Chloride -119 mmol/L
*Serum electrolytes:
Sodium - 138mEq/L
Potassium - 3.3 mEq/L
Chloride - 99 mEq/L
Calcium ionized - 1.01 mmol/K

26/5/2023:-
*Blood urea- 35 mg/dl
*Serum Creatinine - 1.0 mg/dl
*Serum electrolytes:-
Sodium - 135mEq/L
Potassium- 3.2 mEq/L
Chloride- 98mEq/L
Calcium ionized - 1.09 mmol/L
*24 hours urine protein/Creatinine Ratio:-
24hrs urine protein - 2304 mg/day
24hrs urine Creatinine - 1.02 g/day
Ratio- 2.30
Urine volume- 3,200 ml
*24 hours urinary chloride:- 402 mmol/day
*24 hours urinary sodium:- 436 mmol/day
*Bacterial culture and sensitivity:-
Blood- skin commensals growth
Urine- No growth.

27/5/2023:-
Hb:-11.4 gm/dl
TLC:-17,400 cells/cumm
Neutrophils:-90 %
lymphocytes:-5%
Eosinophils:-0 
Pcv- 33.7vol%
RBC count - 3.78 millions /cumm
Platelet count- 1.75 lakhs/cumm

16/6/2023:-
Hb- 10.3 gm/dl 
TLC - 12,500
Pcv- 31.3 %
RBC -3.57
Platelet -2.36 lakhs


30/5/2023
Chest x ray after ICD tube 

grade 4 bed sore
 
 
----------------------------------------------------------------------------------------------------------------

SHORT CASE I
 

A 39 year old male presented with chief complaints of 

shortness of breath since since 6 months 

Generalised body swelling since 6 months

Decreased urine output since 6 months.


HISTORY OF PRESENTING ILLNESS:


Patient was apparently asymptomatic 3 and half years back ,

then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.

Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.

History of mild shortness of breath and chest pain 2 years back, which is not associated with cough or fatigue for which he went to a local hospital where he was told to have uncontrolled blood pressure and patient was started on cilnidipine.

Since then complaints were decreased in frequency but did not subsided.

Shortness of breath worsened 18 months back from exertion to even at less than ordinary activity ( NYHA Grade 2 to 3 which is associated with bilateral pedal edema, pitting type, upto the knees.

H/o fever 16 months back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month) relieved with medication sputum was negative for cbnaat.

In February 2022 patient presented to our hospital with complaints of worsened shortness of breath even at rest, Diagnosed to have Acute pulmonary edema secondary to heart failure and Renal Failure and treated conservatively with Diuretics and Anti hypertensives. Symptoms relieved and patient discharged with online follow up.

8 months back in view of refractory pulmonary edema and metabolic acidosis patient was initiated on hemodialysis and continuing maintainance hemodialysis regularly with frequency of 2-3 times per week.

Current admission : 


Patient presented with Shortness of breath at rest and intermittent generalised body swelling and distension of abdomen since 6 months 

Fever since 1 month


Shorteness of breath initially on exertion which gradually worsened to shortness of breath at rest associated with distension of abdomen.


Fever which is high grade, intermittent type associated with chills not associated with nausea, vomiting, altrered sensorium, cough and burning micturation. 


personal psychosocial  history:-


37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.


All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion


Psychological illness in current admission : 


Since 6 months patient has family disputes with wife and mother in regards to his health, addictions ( tobacoo chewing )

4 months back in a huge argument among the couple , his wife left him alone and reached her maternal home along with there children. Since then he couldn't sleep at night even he doesnt feel breathless.

On further enquiry He emotionally broke down and remembered sleepless nights he spent in memories of his children. Since then he was emotionally upset which hampered self care and stopped taking Tab. Telma 40 mg and Met XL 50 mg ( both due to ignorance and financial issues ). Increased water intake with altrered food habbits.


Problems to be addressed


1. Depression


2. Tobacco deaddiction


PAST HISTORY:


No similar complaints in the past.

No significant medical or surgical history

Not a known case of DM, bronchial asthma, CAD, Epilepsy


FAMILY HISTORY:


 No family history of HTN, DM, bronchial asthma, epilepsy


PERSONAL HISTORY :


Sleep disturbances since 6 months

Appetite improved since dialysis but decreased since distension of abdomen

Decreased urine output and no constipation.

Patient is a chronic alcoholic and chronic smoker since 15 years

Alcohol 90-150 ml per day whiskey/brandy 

1-2 beedi per day for 15 years

Tobacco chewing daily Since 15 years 


Examination


Patient is conscious, coherent, cooperative well oriented to time place and person. 

Thin built and moderately nourished.


Vitals : 

Bp 140/70 mmhg

HR 110 bpm

Temp 103.5F

RR 24-26 cpm


Positive findings : 


General examination


Temporal wasting


Prominent superficial temporal vessels


Pallor


Dry and Bald tounge


Mild Pectus excavatum ( false finding may be due to grossly distended abdomen )



Bilateral pedal edema



Systemic examination : 


Cardiovascular system : 


Raised JVP seen above the angle of mandible in sitting position





Diffuse visible precordial pulsations





Diffuse Apex beat with lateral most palpable at left 6th intercostal space lateral to mid clavicular line

Parasternal heave present

Palpable P2 present


Pansystolic murmur present best heard at apex and radiating to left axilla

Grade 4/6


Per Abd examination :


Grossly distended abdomen 

Fullness of flanks

Umbilicus everted 

Subcutaneous soft swellings consistent with lipoma





Tenderness present at needle insertion site ( last paracentesis 3 days back )

No organomegaly


Fluid thrill present


Respiratory system : 


Bilateral air entry present,  crepitations in bilateral infra axillary area.





Central nervous system :


No focal neurological deficits. 

INVESTIGATIONS :


Hemogram : 


Haemoglobin: 5.1gm/dl

Total count:6,200 cells/cu mm

Neutrophils: 80

Lymphocytes: 10

Eosinophils:02

Monocytes:08

Basophils:00

PCV:16.1

MCV:85.2

MCH:26.9

MCHC:31.6

RDW CV:15.6

RDW SD:47.7

RBC count:1.89

Platelet count: 1.2 lakh

RBC:microcytic hypochromic few pencil cells

WBC:within normal limits

Platelets:count decrease on smear

No hemo parasites seen

Impression: microcytic hypochromic anemia with thrombocytopenia


2D Echo


Right atrium dilated,Right ventricle dilated,left atrium dilated,left ventricle dilated,concentric LVH+

ESD:4.74

EDD:6.58

DPW:1.38

EF:52%

FS:26%

IVS:1.38

Aorta:3.85

Pulmonary artery:Dilated

Pericardium:minimal PE(+)

IVS size(2.27cms)

Mitral flow:E>A

Aortic flow:1.69

Pulmonary flow:1.10

Tricuspid valve:Rvsp=70+10=80mmhg

Severe TR with PAH:moderate to severe AR/MR

Global hypokinesia,no as/ms

Fair LV function

No diastolic dysfunction,no LV clot



RFT :


Urea:72

Creatinine:7.3

Uric acid:6.0

Calcium:9.6

Phosphorus: 4.4

Sodium:143

Potassium: 4.3

Chloride: 101


LFT :


Total Bilirubin:0.87

Direct Bilirubin:0.17

SGOT:17

SGPT:20

Alkaline phosphate:132

Total proteins:6.0

Albumin:2.7

A/G Ratio:0.85


 USG Abdomen :


Liver- Normal size and echogenic 

Spleen-10cm Normal size and echogenic

Rt kidney-7.5×3.1cm

Lt Kidney-7.6×3.2cm

CMD lost

U.bladder minimally distended

No lymphadenopathy

Gross Ascites

Impression:B/L Grade 2-3 RPD changes

Gross Ascitis


Serum iron:79

RBS:85


Ascitic fluid Analysis :


Sugar:104

Protein:3.0

Ascitic Fluid Amylase:36.1

Ascitic fluid for ldh:110

SAAG

Serum Albumin:2.7

Ascitic Albumin:1.54

SAAG:1.75


 LDH:215.7


HIV1/2 Rapid test Non reactive

HBsAg-RAPID is Negative

Anti HCV Antibodies :Non reactive

Problem representation


39M with Chronic kidney disease with Heart failure and pyrexia.


Problems to be tackled


Ascites

Shortness of breath

Fever

Anasarca


----------------------------------------------------------------------------------------------------------------------------------------


SHORT  CASE II

 

 A 60 year old male, ambulance driver by occupation & resident of appalguda thanda of suryapet district presented to OPD with chief complaints of 

Chief complaints :


Red coloured urine since 2 months

Shortness of breath since 45 days

Generalised weakness since 30 days

Constipation since 6 days 


HOPI :


Patient was apparently asymptomatic 2 months back. Then he noticed red coloured urine, which was insidious in onset, gradually progressive. Increased in frequency of urine, mainly during night time. 



Incontinuity of urine is present, at first patient passes red colour urine for few seconds followed by decreased urinary stream associated with sensation of obstruction and pain, after intense pressure he passes dark coloured clots and then normal stream of red coloured urine.

He also has burning micturition and supra-pubic pain while passing urine.

Patient also has compliants of constipation since 6 days which resolves on taking medication. 


H/o giddiness.

H/o tremors .

No H/O fever, weightloss

No H/O loss of appetite 

No H/O cough and hemoptysis

No H/O nausea,vomiting,loose stools. 

No H/o orthopnea and paroxysmal nocturnal dyspnea.

No H/O abdominal distension, abdominal pain.

Past History: 


History of hydrocele, since 15 years.



He worked as a driver for 20 years.

History of trauma 15 years back, while lifting the lorry back door, he slipped and fell during this. 

After this incident in 1-2 months he noticed a swelling in the right groin which is gradually increased in size, painless. Later he neglected the swelling as there was no pain.


Not a k/c/o HTN, diabetes, asthma, epilepsy, TB.

No H/O any past surgery.

He has a H/O fracture of left humerus at distal end, when he was 20 years old, while cutting a tree. Then he got treated for it with reduction and plaster of Paris. But the treatment resulted in maluni7on.


Personal History:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder: constipation since 6 days 

Addictions:

 Alcohol intake every day  (90ml) from 30 years, stopped 2 months back.

Smoking daily 20 beedi in 1 day from 30 years,stopped 2 months back 


Family history:


No significant history.


General examination:


Patient is conscious, coherent, and co-operative. Well oriented to time place and person.


He is moderately built and moderately nourished.


Pallor- present




Icterus- absent

Cyanosis- absent

Clubbing- absent

No lymphadenopathy

No edema


Vitals :


Temperature- Afebrile

Blood pressure- 120/80mm hg

Pulse rate- 96bpm

Respiratory rate- 20cpm


Systemic examination:


Per abdomen: 


On inspection:





Shape of abdomen: scaphoid


Umbilicus: inverted


Movements of abdominal wall with respiration


Scars present( due to beliefs that it helps in digestion, done in childhood)


Swelling in scrotum.(hydrocele?)


No visible peristalsis, pulsations, sinuses, engorged veins.


On palpation:


All Inspection findings are confirmed


No local rise of temperature 


Soft and non tender


No palpable masses


Liver is not palpable


Spleen is not palpable


On percussion:


Tympanic note present


On auscultation:


bowels sounds heard


CVS examination:


Inspection:


No raised JVP


Trachea appears to be central


The chest wall is bilaterally symmetrical 


No dilated veins, scars or sinuses are seen


Palpation:


Trachea central in position 


Apex beat is felt in the fifth intercostal space, 1cm medial to the midclavicular line


Auscultation:


S1 S2 heard


No murmurs 


Respiratory examination:


Shape of chest is elliptical, bilaterally symmetrical


B/L airway entry present


Normal vesicular breath sounds


CNS Examination:


Conscious, coherent, cooperative and well oriented


Normal speech.


No neurological deficit found.


 DIAGNOSIS:


Severe Anemia secondary to blood loss (Hematuria) 


? Urothelial malignancy with right sided vaginal hydrocele .

 





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